Pterional craniotomy

Pterional craniotomy

The resulting bone flap is centered over the depression of the sphenoid ridge. Approximately 33% of the craniotomy is anterior to the anterior margin of temporalis muscle insertion, ≈ 66% is posterior.

With the craniotome, starting at the frontal burr hole the craniotomy is taken anteriorly across the anterior margin of the superior temporal line, staying as low as possible on the orbit (to obviate having to rongeur bone, which is unsightly on the forehead). The distance “B” from the medial extent of the craniotomy to the frontal burr hole is 3 cm for anterior circulation aneurysms. For the approaches to skull base (e.g. Dolenc approach), distance “B” is larger and takes the opening to ≈ the mid orbit. Then from point “B,” a sharp superior turn is made and the opening is taken back to point “A.” The height (“H”) of the craniotomy needs to be only ≈ 3 cm for aneurysms of the Circle of Willis, and slightly larger (≈ 5 cm) for the middle cerebral artery aneurysms. Minimal exposure of the temporal cortex is necessary for aneurysms of the skull base region. For large flaps (e.g. for tumors), “H” is made larger to expose more temporal lobe.


Frontotemporal craniotomy under regional anesthesia during awake craniotomies provides better pain control, a reduction in opioid use, and less somnolence in the early postoperative period 1)


Frontotemporal craniotomy, also known as “pterional craniotomy” (PC), provides an optimal microscopic exposure and a wide open working space for manipulation of intracranial structures, and it has been widely used in the field of neurosurgery for treatment of lesions in the anterior and posterior circulations 2).

The pterional craniotomy provides wide, multidirectional access to the anterior and middle cranial fossae as well as many structures of the interpeduncular fossae.

Other frontotemporal craniotomies derived from the pterional 3) 4) and supraorbital 5) craniotomies, as are the combined epi- and subdural approach with anterior clinoid removal 6) 7) and the orbitozygomatic extension of the pterional craniotomy 8) 9).

The pterional craniotomy is well established for microsurgical clipping of most anterior circulation aneurysms. The incision and temporalis muscle dissection impacts postoperative recovery and cosmetic outcomes.

The minipterional (MPT) craniotomy offers similar microsurgical corridors, with a substantially shorter incision, less muscle dissection, and a smaller craniotomy flap.


Although pterional craniotomy and its variants are the most used approaches in neurosurgery, few studies have evaluated their precise indications.

da Silva et al., evaluated the pterional (PT), pretemporal (PreT), and orbitozygomatic (OZ) approaches through quantitative measurements of area, linear, and angular exposures of the major intracranial vascular structures.

Eight fresh, adult cadavers were operated with the PT, followed by the PreT, and ending with the OZ approach. The working area, angular exposure of vascular structures and linear exposure of the basilar artery were measured.

The OZ approach presented a wider area (1301.3 ± 215.9 mm2) with an increase of 456.7 mm2 compared with the PT and of 167.4 mm2 to the PreT (P = 0.011). The extension from PT to PreT and OZ increases linear exposure of the basilar artery. When comparing the PreT and OZ, they founded an increase in the horizontal and vertical angle to the bifurcation of the ipsilateral middle cerebral artery (P = 0.005 and P = 0.032, respectively), horizontal angle to the basilar artery tip (P = 0.02), and horizontal angle to the contralateral ICA bifurcation (P = 0.048).

The OZ approach offered notable surgical advantages compared with the traditional PT and PreT regarding to the area of exposure and linear exposure to basilar artery. Regarding angle of attack, the orbital rim and zygomatic arch removal provided quantitatively wider exposure and increased surgical freedom. A detailed anatomic study for each patient and surgeon experience must be considered for individualized surgical approach indication 10).

see pterional approach.

Pterional craniotomy complications.

Left pterional craniotomy for thrombectomy and clipping of ruptured left MCA giant aneurysm

Mini-pterional craniotomy


1)

Bojaxhi E, Louie C, ReFaey K, Gruenbaum SE, Leone BJ, Bechtel P, Barbosa MP, Chaichana KL, Quinones-Hinojosa A. Reduced Pain and Opioid Use in the Early Postoperative Period in Patients Undergoing a Frontotemporal Craniotomy under Regional vs General Anesthesia. World Neurosurg. 2021 Jun;150:e31-e37. doi: 10.1016/j.wneu.2021.02.009. Epub 2021 Mar 5. Erratum in: World Neurosurg. 2022 Apr 19;163:2. PMID: 33684585.
2)

Kang HJ, Lee YS, Suh SJ, Lee JH, Ryu KY, Kang DG. Comparative analysis of the mini-pterional and supraorbital keyhole craniotomies for unruptured aneurysms with numeric measurements of their geometric configurations. J Cerebrovasc Endovasc Neurosurg. 2013 Mar;15(1):5–12.
3)

Yasargil MG: Microneurosurgery. Stuttgart: Georg Thieme, 1984, Vol I
4)

Yasargil MG, Fox JL, Ray MW: The operative approach to aneurysms of the anterior communicating artery, in Krayenbül H (ed): Advances and Technical Standards in Neurosurgery. Wien: Springer-Verlag, 1975, Vol 2, pp 114–170
5)

Jane JA, Park TS, Pobereskin LH, et al: The supraorbital approach: technical note. Neurosurgery 11:537–542, 1982
6)

Dolenc VV: A combined epi-and subdural direct approach to carotidophthalmic artery aneurysms. J Neurosurg 62:667–672, 1985
7)

Dolenc VV, Yasargil MG: Anatomy and Surgery of the Cavernous Sinus. Wien: Springer-Verlag, 1989
8)

Fujitsu K, Kiwabara T: Zygomatic approach for lesions in the interpeduncular cistern. J Neurosurg 62:340–343, 1985
9)

Hakuba A, Liu S, Nishimura S: The orbitozygomatic infratemporal approach: a new surgical technique. Surg Neurol 26: 271–276, 1986
10)

da Silva SA, Yamaki VN, Solla DJF, Andrade AF, Teixeira MJ, Spetzler RF, Preul MC, Figueiredo EG. Pterional, Pretemporal, and Orbitozygomatic Approaches: Anatomic and Comparative Study. World Neurosurg. 2019 Jan;121:e398-e403. doi: 10.1016/j.wneu.2018.09.120. Epub 2018 Sep 26. PubMed PMID: 30266695.

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